Pink Arrows Retreat Application Form (August 17-19, 2026)
Are you Deaf, DeafBlind or hard of hearing? Have you been diagnosed with breast cancer? Apply to attend Canada’s first DDBHH retreat at Deaf Culture Retreat Centre (DCRC) owned by Canadian Cultural Society of the Deaf in Grande Digue, New Brunswick! This is open to anyone who is 21 years old and up and fit the criteria for this type of event.
Registration
Please complete all sections to be considered for participation. If you have any questions, please contact Lucia Jackson at pinkarrows1@gmail.com
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Cell number (text)
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
Please select a month
January
February
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June
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Month
Please select a day
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Day
Please select a year
2026
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Year
Are you:
Deaf
DeafBlind
Hard of hearing
Hearing
Are you a Canadian citizen?
Yes
No
You are currently residing at the address provided above:
Yes
No
Are you:
Working full time
Working part time
Not employed
a full time student
a part time student
semi retired
retired
Gender Identity
*
Woman
Non-binary
Prefer not to say
Other
Your preferred language is:
ASL
LSQ
Other
Medical Information
The following questions are regarding your current medical and health situations. Please be aware that we are unable to provide medical assistance at this retreat. Each participant must be physically independent and able to administer their own treatments and/or medications as needed. We are not able to accept medical aids or any other caregiver to attend the retreat with you.
What year were you diagnosed with breast cancer?
Please tell us a little bit about your breast cancer diagnosis.
Have you been diagnosed with metastatic breast cancer? (Stage 4)
Yes
No
Will you be in active treatment at the time of this retreat (ie. Chemotherapy, radiation or recovering from a recent surgery)?
What is your comfort level with stairs?
I am totally comfortable going up and down the stairs (ie. to go to and from my bedroom)
I can handle a few stairs here and there
A step or two into the home is fine as long as activities throughout the day are all on the first floor
I cannot do stairs at all (I use an elevator)
Do you have a heart condition? If yes, please specify.
Do you have diabetes?
Yes
No
Do you have sleep apnea?
Yes
No
Do you have asthma?
Yes
No
Do you use oxygen or a CPAP machine?
Yes
No
Please list any dietary restrictions, food allergies or intolerances.
Do you have any severe allergies that require an EpiPen? If so, please list. (Severe = anaphylactic response)
Please list any medications that you are currently taking. Please include current doses.
Are you able to provide a supporting letter from your doctor that it is safe for you to attend the retreat?
Yes
No
Emergency Information
Emergency Contact Name
Emergency Contact Number (text)
Relationship to this person (example: mother)
How did you hear about this retreat?
Please Select
Friend or family
Social media
Email newsletter
Website
Other
Cancellation Policy
I acknowledge that I have read and understand the cancellation policy. Due to the high demand for this one of a kind no-cost retreat, a $100 deposit is required to hold your spot. This deposit is eligible to be fully refunded following the retreat. Although we sincerely hope that you will be able to attend this retreat you registered for, we do understand that schedules and situations may change. If your application is not accepted for any reason, the money will be sent back to you. If accepted but you must cancel, we respectfully ask you to give us a minimum of 60 days notice. This will allow us time to try to fill your spot. To receive your full deposit back, you must contact Lucia Jackson at pinkarrows1@gmail.com and ask to cancel by June 1st, 2026 at 11:59 PM EST. Cancellations made after that will no longer be eligible to be refunded. No exceptions.
If you have been accepted to participate in the retreat, you will be responsible for your own actions as a guest.
Yes, I understand
Please be aware that this is a first come, first serve based on submissions from all over Canada. There are 8 spots to be filled in. If we are full, do you wish to be on the waitlist for the next one?
Yes
No
Retreat space is very limited so a $100 deposit is required to hold your space and secure meals, etc. Full refund of your deposit will be issued following your retreat. Send via e-transfer to pinkarrows1@gmail.com [Note: the deposit won’t be refunded if you back out anytime after June 1, 2026 at 11:59 PM EST]
Please Select
I will make a deposit.
I will not make a deposit.
Submit Application
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